Afterload Mismatch After MitraClip Insertion for Functional Mitral Regurgitation

Afterload mismatch after transcatheter mitral valve repair with MitraClip for degenerative mitral regurgitation in acute cardiogenic shock

“…Biner et al reported acute improvement in patients with severe MR and hemodynamic compromise after MitraClip repair , but did not report any acute afterload mismatch. Melisurgo et al reported the phenomenon in patients with functional MR and cardiomyopathy, particularly those with poor LV function, enlarged LV dimensions, right ventricular dysfunction, and pulmonary hypertension . Despite our patient having no known risk factors for afterload mismatch , such a phenomenon may exist in patients who undergo acute MR reduction, and should be on one's differential diagnosis when a patient acutely deteriorates following MitraClip repair.…”

“…Melisurgo et al reported the phenomenon in patients with functional MR and cardiomyopathy, particularly those with poor LV function, enlarged LV dimensions, right ventricular dysfunction, and pulmonary hypertension . Despite our patient having no known risk factors for afterload mismatch , such a phenomenon may exist in patients who undergo acute MR reduction, and should be on one's differential diagnosis when a patient acutely deteriorates following MitraClip repair. In our case, we might have underestimated the severity of acute hemodynamic stress on the LV as a result of her acute severe MR. After MitraClip repair, we saw such a dramatic clinical improvement that we quickly weaned off her mechanical circulatory support, which on hindsight likely unmasked her severe LV dysfunction and resulted in her acute hemodynamic deterioration.…”

“…Afterload mismatch after surgery for mitral regurgitation (MR) with transient left ventricular (LV) dysfunction is well known . Similar phenomenon has not been described after transcatheter mitral repair with MitraClip (Abbott Structural Heart, Santa Clara, CA) except in patients with functional MR and cardiomyopathy . MitraClip repair in the setting of acute cardiogenic shock has also been rarely reported .…”

Intra‐aortic balloon counterpulsation pump in heart failure patients during MitraClip implantation—A propensity‐score matched analysis

“…The mechanisms leading to further left ventricular impairment during mitral valve repair are not entirely understood. Concerns regarding the afterload mismatch occurring during the procedure have been described previously, and might be only one explanation for peri‐ or postprocedural adverse events in patients with advanced heart failure. A successful mitral valve repair leads to a relevant reduction of the regurgitation volume and results in an acute increase of the left ventricular filling pressure and consecutively leads to an immediate afterload elevation .…”

How heavy is the load? The ventricular mechanics of mitral regurgitation revisited in the era of percutaneous therapies

“…Thus, mean LV pressure during the regurgitation period is markedly lower than the value of mean LV pressure measured exclusively during ejection (see figure 1A, B, E). In fact, equalisation of regurgitant and ejection mean LV systolic pressures is the mechanism by which percutaneous edge-to-edge mitral valve repair abruptly rises systolic wall-stress (immediately after closing the regurgitation),4 potentially causing an acute afterload mismatch in very poor and dilated ventricles already supporting an extreme wall-stress at baseline 5…”